Financial Stress: Impact on HIV Adherence, HCV and Prescribing Patterns
October 30, 2012
Adherence -- taking medicines exactly as prescribed -- is critical to the success of medications and treating illness, particularly infections. In order for potent combination anti-HIV therapy (commonly called ART or HAART) to result in sustained improvement in health, a very high rate of adherence -- at least 95% -- is required. There are many factors that can affect adherence in people with HIV and other conditions, including depression, medication-related side effects and competing priorities such as substance use.
Cost issues have been identified as one potential barrier that can affect adherence to ART -- certainly this is the case in low- and middle-income countries. In contrast, in high-income countries such as Canada, Australia, the U.S. and Western Europe, the cost of HIV treatment is heavily subsidized by governments. Thus the cost of care and treatment is not expected to affect adherence, as in many high-income countries universal health care is available to citizens and permanent residents.
In high-income countries, a large proportion of HIV-positive people are on disability support payments because they are unable to work (as such, their income is low). It is likely that they experience financial stress, though how this might affect adherence to HIV treatment has not been explored in detail until recently.
Australia's leading clinic for HIV, other infections and immunological disorders is at St. Vincent's Hospital in Sydney. There, researchers keep track of Australia's HIV epidemic. They noticed that for the past several years about 3% of Australian HIV-positive patients appeared to be dropping out of care. Motivated by this and also by reports from their patients about financial stress, a research team at the hospital launched a study to explore the issue of financial stress and adherence within a larger survey about health and care.
The Sydney team found that a significant proportion of patients were experiencing financial stress and were delaying the purchase of medicines. Furthermore, some patients disclosed that as a result of financial stress they had stopped taking and/or buying prescribed medicines. Patients also disclosed that the cost of transportation to the HIV clinic was a financial barrier. Researchers also found that transportation costs had caused some patients to interrupt ART -- a decision that can be fraught with serious health consequences.
The cost of health care is something that is drawing concern not only at the individual level but also at the regional and national level in many countries. Already in Western Europe, much of which is experiencing a recession, proposals are being floated to further reduce the costs of treatment, including the use of simplified anti-HIV regimens. Such proposals may become more widely discussed in the future if the financial-economic crisis continues.
Researchers invited clinic patients to participate in an anonymous survey about care and treatment issues, including financial stress. A total of 500 people completed the survey. Limited information was available on the profile of participants, as follows:
Results -- Focus on HIV-Positive Patients
Among the 335 HIV-positive patients, the following proportion acknowledged problems meeting pharmacy-dispensing costs as follows:
Participants acknowledged the cost of paying for transport to meet clinic appointments with the following impacts:
Of the 65 participants who stated that they had a degree of difficulty paying pharmacy costs, nearly 30% stopped taking their medicines. In contrast, of the remaining 270 HIV-positive patients who did not disclose financial stress, only 4% said that they stopped taking medicines (for unknown reasons). This difference in rates of discontinuation was statistically significant.
Talking About Money
At clinic visits, doctors often asked patients about their health and medicines. For instance, 60% of participants reported that they were always or frequently asked if they were experiencing side effects because of medication. Only about 5% were often asked if they had difficulty meeting the costs of medicines.
The design of the study was cross-sectional in nature. This is analogous to a snapshot taken at one point in time. Cross-sectional studies are cheaper, faster and simpler than other types of studies (such as those that run for many years). Cross-sectional studies cannot provide definitive answers to research questions. However, their findings can be explored in studies of a more complex (and expensive) design.
Another limitation of the present study is that the vast majority of participants were male. The research team noted that women "generally earn less money than men," and so financial stress on them would likely have been greater.
Despite these limitations, the Australian study is very important and will have a major impact on future studies of adherence in high-income countries.
This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication CATIE News. Visit CATIE's Web site to find out more about their activities, publications and services.
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